“I have a voice in my head” does not tell us enough about what somebody is experiencing. It might refer to ordinary self-talk, an intrusive thought, a remembered argument or an experience that feels separate from the person’s own thinking. The phrase needs exploration before a practitioner decides what it means.
Listening carefully means attending to the person’s language without forcing it into a familiar model. It also means remembering that the voice is one aspect of a life. The person has relationships, circumstances, intentions, fears and abilities that cannot be reduced to a single symptom or sensory channel.
From The Rainbow Machine: Tales from a Neurolinguist’s Journal by Andrew T. Austin.
A description is not yet an explanation
NLP often begins by distinguishing visual, auditory and kinaesthetic aspects of experience. What picture does the person make? What do they say to themselves? What do they feel? These can be useful questions, but they become restrictive if the answers are treated as the sum total of human experience.
A disagreement with a parent is more than an image and a soundtrack. It may involve dependence, loyalty, anger, practical consequences, remembered humiliation or uncertainty about what happens next. Changing the imagined volume might alter something about the experience without resolving those relationships.
There is also a difference between using a model to notice more and using it to stop noticing. If every difficulty becomes a picture to move or a voice to quieten, the technique has started selecting the problem. Enquiry should allow the person’s account to challenge the practitioner’s expectations.
Who is speaking, and who is being addressed?
Consider several expressions: “I say to myself that I am no good.” “I tell myself, Andrew, you are no good.” “I have a voice in my head saying you are no good.” The grammatical differences do not establish a diagnosis, but they invite different questions.
In the last sentence, who is “you”? Is the voice addressing the speaker, another person or somebody imagined? Does the speaker agree with it? Is it experienced as a thought, as speech or in some other way? Does it use the person’s own name? Is there a sense of deliberately producing it, or does it arrive uninvited?
NLP uses the term referential index for the person or thing to which a word refers. Losing track of that reference can lead a therapist to work confidently on the wrong relationship. An apparently self-critical sentence might be a judgement about somebody else. The distinction should be checked, not silently assumed.
An uncomfortable session
I was once asked to see a woman who had already worked with another therapist. Before meeting her, I had reviewed recordings and notes and spoken with the practitioner. She knew that background information had been shared. When I nevertheless opened by asking what the problem was, she had good reason to find the question tiresome.
My recollection of her reply is that she had a voice in her head saying “you are no good.” The exact wording has become less certain through repeated retelling, so it should not be treated as a verbatim transcript. What caught my attention was the possibility that the sentence did not mean what previous conversations had assumed it meant.
I heard a possible judgement directed towards me: she thought I was no good. The session that followed was poor in several respects, and she left very unhappy. She later wrote a lengthy criticism of me and the work. In that same account, she reported an improvement of about eighty per cent across her symptoms.
It would be convenient to turn that sequence into a clever, deliberate intervention. The honest account is less tidy. Some of what happened was intentional and some was not. Her reported improvement was encouraging, but it did not establish that my interpretation or my poor performance caused it. Her dissatisfaction also remained valid feedback; an improvement report does not cancel a complaint.
When people learn the language of their therapy
Someone who has spent years in a particular therapeutic environment may start describing experience in its preferred vocabulary. Instead of saying “I think,” the person says “I have an auditory representation.” Instead of describing an argument, they identify a part, a trigger or a programme. The language can reveal useful distinctions, but it can also become a script.
Practitioners participate in this learning. Repeatedly asking where the voice is, how big the picture is or which part is responsible suggests which answers count. A client may become fluent in the model without gaining much ability to handle everyday life. Familiarity with the vocabulary is not evidence that the underlying interpretation is correct.
A useful check is to ask for a description in the person’s own ordinary words. What happens during a normal day? What is difficult about it? What do they do next? What would they like to be able to do? The model should help illuminate those answers rather than replace them.
Voice hearing and clinical assessment
It is important not to assume that every reported voice is simply ordinary internal dialogue. Hallucinations can have a range of causes, and their apparent location alone does not establish the cause or the appropriate treatment. The NHS guidance on hallucinations and hearing voices describes possible causes, including mental and physical health conditions, medicines, substances and temporary circumstances such as sleep deprivation.
A person’s experience may feel vividly real and involuntary. Telling them they are merely talking to themselves can be dismissive and can miss a need for assessment. Equally, hearing the word “voice” should not lead an unqualified practitioner to announce schizophrenia. Ask for appropriate clinical help while taking the account seriously.
The NHS advises urgent medical help for hallucinations, and emergency help when voices direct someone to harm themselves or another person, or when there is sudden confusion, severe agitation or rapid worsening. These situations require more than an exercise in changing an imagined sound.
Identity can shape what listeners hear
There is a difference between saying somebody has a diagnosis and treating that diagnosis as the whole person. A familiar complaint can be interpreted differently once the listener knows a psychiatric label. “I am still arguing with him in my head” might be understood as ordinary rumination in one person and immediately treated as a symptom in another.
The answer is to investigate the actual experience in both cases. How persistent is it? How distressing? How much does it affect sleep, activity, relationships or safety? What does the person mean by arguing? Neither automatic normalisation nor automatic pathologising provides enough information.
Changing the label patient to client or customer does not, by itself, change the relationship. Respect is demonstrated in how the person is listened to, what choices they have and whether their account can correct the professional’s assumptions.
Skills and support alongside treatment
A person need not be offered only the alternatives of complete cure or no help at all. It can be worthwhile to develop ways of responding to distress, recognise patterns, improve daily routines and identify situations in which support is needed. Goals can concern participation in life as well as the presence or absence of a voice.
Psychological work is not excluded by a diagnosis of schizophrenia. NICE recommends CBT and family intervention within appropriate care, including psychological interventions alongside medication for first-episode psychosis. That is different from claiming that a generic NLP exercise treats schizophrenia.
In work with ordinary critical self-talk, ask what the commentary does, when it starts and how the person responds. With persistent or distressing voice hearing, work within suitable clinical support and competence. In either setting, the person should be able to say that a proposed explanation does not fit, that an exercise is unhelpful or that their priorities are different from the practitioner’s.